00100153 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION-
BUILDINGADDRESS: I%RMIr NO. Q.!IRA VISTA AV
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ON'NNR'S N h c"U APPLICATION SUR DAIS
PII(INIi; ASREAU ` SANITARY O. COs"Ol.NO,
M O C ARCHI'I EC'FAiNGINLGR: RUILD16f PERMIT INFO
E Bloc IiLF.CT PLUMn MEC
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o Sw" LICENSti' WNTRACrderi DECLARATION
�� I nanny norm;th:v I um liccnved under pnrvl,inm o[Chnpmr 9(u,mmencing Job Description
p:pau with Section 71100)of Division l floc B.'aw's and Pmfessions Gdc.and my license
¢ •a sin full lilac and diR
go y I.iears 'bie 1`3 Lie.x_ �3 7�' SEWER REPAIR
Dare_/Z�=O_O Cona:mn,
3 a H ANCIII"1 E(,T'g DECL,
x1 unJedunJ my plain mall w used as pit is recce d,
/0 /` C
w i B O Licemcd professional
� d oa OWNER-BUILDER from he CommeN
w:y 1 hcmhy.(Sere that 1 1. exempt from the Ciowt,Co e:A., Law far the
!'>�' following (Section t 9lDsmic,alainrPml'e,eainnc Gate Any city oreounty
4 O which¢yuirev n per;nil h.conrtnmt altar,improve,JvmulidM1,or repair any structure O
y,_ea prior hat its issuance.also requires the applicant lot such permit to lilt a sigtwd stme:nad
— tUtheisl¢emedpdistant a,the pmvismttold,cContraomr"Lira c Law(chapter 9 Sq. Ft. Floor Area
nsValuation
(cummcodng with Sart ion 70da))of Division 3 of the Business and professions Code)
on Ihm he i.e.exempt nerefmnt and the bus is tar the alleged cscansion,Any violadn I
of Sectinu 7031,5 by any applicant for a Amain subjects the applicant to u civil penalty
ofnat mare than five hundred dollars s50o). APN Number Occup n(i' pe
❑1,a,owner orae pmpcny,or my employees with wages a,their ale amin't ndimm.
will Jo the work,and the structure 1,not tneaded or olle,ed for sale(Sec.7614. ,;j_t/Q1
Business:Ind Prnfes.doas Code:The Contractor:,License law uses or apply to an equired Inspections .
r of property Who wilds or immature,thereto,and who does such ss
work hincl l'
orthough his two anploycesprovided that sueM1 inmmvcmcm,are not intended or
offered for,Ile.If.however.the wading or improvement is sold within one year of 106 .— SEWER & WATER
completion.the owner-wilds,will have the bnmenoi pown,mat hadal ren Mdldor — �I _ 1-INDERFLOOP, F'I
inIp _I 114BIPIG
rvva for puToa at sale), Gl c
O1,nrownmol the pmpeny.ame.adocively contracting with licensed contractors it) 301 — PLOUGH PLUMBING
construct he inject(Sea,70,11 B.,mus,and Pmfe,niom Codec nue Contractor, .'—jQt i FINAL F'I_LIIYIB I NG
tl
Live c Law docs urn apply m an o of a corny ww halide se pursuant
bacon,the '
and whit contracts for such projects with a cuntrecmr(x) licensed Puouam m the
Cos exe I.irensc law.
l su
_
❑1;un excnml under Sac ,It&P C for his..on
Owner Data
WORKER'S COMPENSATION DECLARRr1ON
1 heresy ithint under peredty of Perjury one of the following declarations:
❑ I have and will Toamain it Certificate of Convent to silLinwm fm Worker's
Compensation, a, prrnlded it,, by Section 310X1 of the Litho. Code. for the
perhatu nm al the work for Machin,permit is Metal,
❑1 have and will muimain Worker',Cmnpcnsntin I Insurance,as required by Section
3700 of the Labor Cafe,for the rartursepce of the work for which this permit is
issued.Aly Workers Compensation Insurance carder and Poli y Iliac.unit:
Carrier:_,_�IZ-D I•oliey _9.33 r'3
CIiR'n1 ICA'fP UP Exrwn iDN IROM WORKERS'
COMPENSATION INSURANCE
this ,,,,or need nm wcompleted if the Penni,is for one hundred dollar
(Situ)or loss.)
I certify that in the Iscrforvmn.of the veal,fm which this permit is issued.I
shall not employ any person in any ntanner.so as to become subject to the Workers'
Co:np nedion I.aw, It C;ddomia,one
Applicant .
NOTICE TO APPLICANT:11,alter tnaAing this Certificate of Exemption.you should
wenme object m the Workers Comlens uiun provisions of the laver Code.You oma
Inch.kh comply with Inch pavilion,or this,Intuit shall le dcened revoked.
CONST RUCTION LENDING AGENCY
1 herchy alfrnm that mere is a construction lending agency for the performance
W of the work for which this permit is issued(Sec.31N)Z Cir.C.)
L Q Lender',Nn;ne
D 7 Lender's Address
U O correct
c I verily that I have read tbi,,,,dcmLa
lon and me that the above information is
k, E., .I agree h,comply an all city and marry onhumi ccs and sant,laws relating
U ,,handing cmmamain I.nal herebyumh...!,a prnendtive,nl this edym ener.ram
ythe alloc.luentioned parm,any for inspection purposes.
(w) g I,sac J T ;nIk pl - Ivs It.-City fCpr oapinst
J) I'ah I'f ts. I J mss ti h Yin unY Y c 6ainst:aid
U z City e e nl th g ,f IM R t /� �j;�
Aty LU )i)rAN ND WI l PIY WITH ALL NON POINT — �yV
sof R1 1 n aNs p Issued by: Dale
S
n: tee or Appfenvcomtrae'" tone Re-root's
HAL,R DOUS MAI'IiRIAI.ti ISCI >Sl11tE
Will
mc:mPlica;h or metre wddnmg a�cnls,n or natdm ima,amJans mmeam Type of Root'
as derneJ by the Cupcnina g1unicipel Cade
Chupmr),I z.and the Henan;rend Safety
Code.Suction 25531 r1 f
❑Yes All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future wilding occupant use equipment or Jaice%which If a roof is installed without first obtaining an inspection, 1 agree to remove
chit hanrdous air e,mraminars as Jdined by the Bay Arca Air Quality Managcmnn
ui,trict't Lir all new materials for inspection. Applicant understands and will comply with
ow, all non-point source regulations.
I have nail the hanallous materials requirements under Chapter 6.95 1)]the
Califus in l],aid,&Sulity Code,Sections 25505.25593 and 25534 1 undacand that
die Is II nw,nut cuncndy hale harms,that it is my re,par,did'tyu,notify the
ueeupnm M mqull:, which mu met prior to is,mmec of a Cerlilicme of
""n Signature of Applicant Date
All roof coverings to be Class"B"or better
O a nntll... ed age Dale
I
OFFICE